What Cognitive Testing Can Miss, and Why the Baseline Matters

Why a “normal” cognitive screening result may not be normal for you, and how Radence looks deeper to understand the whole story of brain health.

October 28, 2026

Cynda Perun

by Julie Chen, MD

Chief Medical Officer, Radence

Most take their first cognitive test after they or a family member notice a problem. Their results are then interpreted in a vacuum. There is no record of their performance from when they were well, so it is difficult to assess what has changed, by how much, and how quickly.

Cancer and heart disease are screened for years before symptoms appear, and as highlighted in a recent Medical Economics article, cognitive health warrants a similar approach. The brain changes behind mild cognitive impairment (MCI), Alzheimer’s disease, and other dementias can build for 10 to 20 years before their first symptoms. Catching them earlier can expand the window to address risk factors and plan care.

Radence addresses the cognitive testing gap by measuring how members function while they are well. That record becomes a personalized baseline used to flag and address change in the years that follow.

Where Conventional Screening Falls Short

Brief screens such as the Montreal Cognitive Assessment (MoCA) take 10 to 15 minutes and sample memory, attention, language, executive function, visuospatial skills, abstract reasoning, and orientation. They can identify moderate to severe impairment but are much less sensitive to early decline, and their scores are judged against population averages rather than an individual’s history.

This is a problem for people who have always functioned at a high cognitive level, those often with advanced education or demanding careers. These individuals typically have a high cognitive reserve which allows the brain to compensate as performance slides due to undetected changes. Someone whose memory and processing speed were once exceptional can decline substantially and still score in the normal range. A personal baseline lets clinicians compare new results with their earlier performance as well as with population norms.

What Comprehensive Testing Adds

A comprehensive neuropsychological assessment, administered by a neuropsychologist over 3 to 5+ hours, evaluates cognitive abilities at significantly greater depth. It uses a set of standardized tests to assess each cognitive domain, including memory, attention, executive function, language, visuospatial skills, and processing speed.

The data gathered across these domains helps point to a cause. Trouble forming new memories is typical of Alzheimer’s disease, slowed processing and difficulty with multistep tasks suggest vascular changes, and changes in planning or behavior with memory intact can indicate frontotemporal dementia. Inconsistent recall can instead reflect medications, attention disorders, sleep apnea, or fatigue. A MoCA screen cannot distinguish among these.

Radence administers the MoCA to every member and repeats it at a regular cadence. Any member can choose to have comprehensive testing to establish a detailed baseline, and Radence recommends it on an individualized basis, especially if:

A member receives a screening score much lower than expected
A family history of dementia
Changes in memory, focus, or behavior noticed by the member or their family
An APOE4, PSEN1, or PSEN2 (or other clinically pertinent neurodegeneration genes) result on genetic testing
White matter changes or other relevant findings on brain imaging

The Radence Testing Framework

Standardized sets of neuropsychological tests exist, but they are not widely used in clinical practice. Most neuropsychologists use their own flexible set of tests, which varies within and across institutions; however, this makes results from one practice potentially difficult to compare with results from another. For a patient who relocates, seeks a second opinion, or sees a new specialist, that could mean a time-consuming retest.

To address this, Radence evaluated more than 95 neuropsychological tests with practicing clinicians at world-leading academic and community institutions. We then refined that test set to those used most routinely by the institutions surveyed. An evidence-informed framework for comprehensive cognitive assessment was then developed using well-established tests selected for broad domain coverage, portability, and practical duration. Almost every test included is sensitive to MCI, the early stage of decline that precedes dementia. Every consulted neuropsychologist stated they would accept results from the framework without retesting, provided it was administered by a credentialed clinician with complete documentation.

When comprehensive testing is warranted, Radence coordinates it with an independent neuropsychologist who is free to adjust it based on their clinical judgment. Because the framework uses widely accepted tests, a member’s results remain interpretable by other institutions and specialists. After a baseline is established, Radence retests at an interval set for each member to gather longitudinal trends and track any new symptoms.

Putting Cognitive Results in Context

Radence reviews cognitive results alongside other measures of brain health. Blood biomarkers such as p-tau217 can detect early Alzheimer’s-related changes from a standard blood draw, and APOE, PSEN1, PSEN2, etc. genotyping identifies genetic risk. Brain MRI through the BioAtlas protocol shows white matter changes, and referral to neurodegeneration specialist to discuss external amyloid PET imaging if findings warrant it. Cardiovascular, metabolic, and family history are considered as well. Slowed processing speed on testing, white matter changes on MRI, and elevated cardiovascular risk, for example, together point to a vascular contribution that can be addressed. Vascular damage and Alzheimer’s-related changes also often occur together, and when they do, symptoms can appear with less Alzheimer’s-related change than would otherwise be expected.

After the Assessment

Neurodegenerative diseases, like Alzheimer’s, can begin in the brain decades before symptoms appear, and cutting-edge treatment timing is crucial to the efficacy and safety of therapy. Recognizing change early, against a personal baseline, keeps more options available.

Radence interprets cognitive findings in the context of each member’s overall health, decides on next steps, and connects members with vetted specialists when further evaluation or treatment is needed. Radence clinicians can join those appointments to share findings with the care team, and they continue to track results over time.

A more complete picture of your health stars with understanding your baseline.

At Radence, cognitive assessment is part of a broader, ongoing understanding of each member’s health. We connect findings across cognitive testing, imaging, biomarkers, genetics, and other clinical information to determine what deserves attention and what should happen next. When specialist evaluation or treatment is needed, we help identify the right expertise, work alongside existing physicians, and stay involved as the picture evolves. We help you understand what is changing while there is still time to act on it.

Explore Radence Membership

The Radence Standard

A different standard than the market is applying - and it will always be the one we hold. If you've been considering membership, we'd welcome the conversation.

Schedule a Membership Consultation

Julie Chen, MD

Chief Medical Officer, Radence

Dr. Julie Chen is the Chief Medical Officer at Radence. She previously served as Chief Medical Officer at companies such as Human Longevity and Vitagene. Her research, at the FDA, NIH, National Cancer Institute, USC, and Mount Sinai, has shaped scientific advancement in precision medicine. As a fellowship-trained integrative internal medicine physician, she developed numerous corporate wellness programs in Silicon Valley focusing on whole-systems approach to healthcare. Dr. Chen is a frequent medical expert on major media outlets, including ABC, NBC, FOX, and MSN, and she has been featured in national magazines and podcasts. In 2023, she was named one of the Top 25 Women Leaders in Biotechnology by Healthcare Technology Report for her leadership in health tech development. Dr. Chen is a member of the Buck Institute's President's Circle, dedicated to advancing research in aging and longevity.

You may be interested in:

Not All Whole-Body MRI Scans Are the Same

At Radence, advanced imaging is a critical part of how we look for disease before symptoms appear. That requires more than access to an advanced MRI scanner. It requires a protocol designed to capture the level of detail needed to identify subtle findings consistently.

That is why we developed BioAtlas, our proprietary whole-body MRI protocol. Every aspect is intentional, from how images are captured and which views are included to who interprets them and how the findings are evaluated alongside other health data.

The result is a more detailed and clinically useful view of your health, designed to give your clinical team better information to determine what deserves attention and what should happen next.

BioAtlas also sits within a broader Radence imaging strategy. When MRI cannot fully answer a clinical question, we incorporate other imaging modalities based on your biology, risk factors, and findings.

The result is a more detailed and clinically useful view of your health, designed to give your clinical team better information to determine what deserves attention and what should happen next.

A Whole-Body MRI Is Only as Good as the Protocol Behind It

Two whole-body MRI scans can be performed on similar scanners, take a similar amount of time, and look nearly identical to the person being scanned, yet provide very different information to the clinical team.

MRI protocols contain hundreds of technical decisions that influence what can be seen and measured: the sequences captured, image resolution, anatomical coverage, slice thickness, coil selection, timing, and even how you are positioned within the scanner. Small differences can affect image quality or determine whether specific quantitative information can be extracted from the exam.

Think of it like photography. Two photographers can use the same high-end camera and photograph the same subject, yet differences in the lens, focus, lighting, exposure, and composition can produce very different results.

That is why Radence defines BioAtlas at a detailed technical level and works directly with our imaging partners to standardize how the protocol is installed, tested, and performed.

What the Scan Doesn’t Capture, You Can’t Interpret Later

Think of an MRI as creating a series of slices through your body, much like slices in a loaf of bread. If there are gaps between the slices, portions of the anatomy are never imaged. If the slices are too thick, subtle abnormalities can become blurred or partially hidden.

BioAtlas was developed with input from leading national experts, across academia institutions and community leaders, with decisions around slice thickness and coverage made intentionally to balance fine anatomical detail with image clarity. The protocol uses thin, gapless imaging designed to capture anatomy with a level of detail that can matter when looking for subtle findings.

Image quality depends on much more than slice thickness. BioAtlas brings together advanced MRI technology, specialized imaging techniques, AI-enabled technology, and carefully vetted imaging environments to produce clean, clinically useful images.

For you, the result is a more complete picture for the clinical team evaluating your health and better information to determine what deserves attention and what happens next.

One View Can Miss What Another Reveals

The angle of an MRI image can change what a radiologist sees.

The BioAtlas protocol captures multiple imaging planes throughout the body, including cross-sectional views in key areas such as the spine.

The difference can be significant. A study indexed by the National Center for Biotechnology Information found that sensitivity for spinal canal narrowing was 55% when the spine was viewed from the side alone, compared with 80% when cross-sectional views were also included.

BioAtlas also takes a deeper approach to the spine itself. The protocol includes imaging that evaluates inflammation and fluid, bone marrow, discs and nerve-related structures. Bone marrow evaluation is particularly important for identifying areas where normal marrow may have been replaced by abnormal tissue, including metastatic disease. Many other whole-body MRI protocols simplify the spine imaging by omitting sequences that evaluate bone marrow in detail.

If you are undergoing screening before symptoms appear, these distinctions matter. The ability to find a subtle abnormality depends in part on whether the scan was designed to reveal it.

Advanced MRI Can Reveal Changes You Can’t See

BioAtlas also provides information about aspects of your health that may not be apparent from appearance, weight, or routine health measures.

AI-driven analysis assesses liver fat, iron, and early fibrotic inflammation. Body composition analysis measures visceral fat, subcutaneous and muscular fat, and muscle quantity, quality, and balance. These metrics can reveal metabolic changes and hidden health risk even when you otherwise appear healthy.

A first scan can help establish your baseline. Over time, we can track measures such as liver fat, visceral fat, and muscle quality, helping us see whether meaningful aspects of your biology are changing, and if those changes require interventions.

The Images Are Only the Beginning

Whole-body imaging asks a radiologist to evaluate a large amount of anatomy, including subtle and borderline findings. Differences in interpretation can contribute to false positives and unnecessary follow-up.

Radence uses a small, hand-selected group of experienced radiologists trained on the BioAtlas protocol, creating greater consistency in how scans are interpreted and helping reduce variability from one reader to another.

Then the clinical interpretation begins.

Does a finding fit with your medical or family history? Does another piece of testing make it more significant? Has it changed from previous imaging? Does it require another modality to characterize it? Should it be acted on now or monitored over time?

For you, this is the difference between receiving a finding and understanding what that finding actually means for your health.

One Scan Cannot Answer Every Question

BioAtlas provides a detailed view of the body. Some questions call for another type of imaging.

Your cardiovascular risk, for example, may warrant coronary CT angiography to evaluate the coronary arteries. Lung risk may point to Chest CT. Bone health may require DEXA. Cardiac structure and function may be better evaluated with echocardiography.

BioAtlas therefore sits within a multimodal imaging strategy at Radence. Your biology, risk factors, and findings help determine which imaging can provide the information your clinical team needs.

For you, it means choosing imaging based on the clinical question we are trying to answer.

The same approach extends beyond imaging. Results can be considered alongside other layers of your health data to give the clinical team additional context around what a finding may mean.

The question guides the test. Your biology guides the care.

A Radiology Report Is Not a Care Plan

Suppose BioAtlas identifies a small abnormality.

What happens next depends on what it is, what else we know about you, and how much clinical significance it carries. It may need another type of imaging. It may need to be watched for change. It may warrant specialist expertise or treatment.

This is where Radence’s role extends beyond testing.

Your Radence clinical team determines what deserves further investigation and helps establish the appropriate next steps. When your existing physician or a specialist should be involved, we work alongside them rather than replacing them.

That involvement can be hands-on. A Radence clinician may speak directly with your physician or specialist to explain a finding, share the broader context behind it, and help determine what should happen next. We will join you in appointments with your other physicians when having the Radence clinical perspective in the room can help inform the conversation and treatment plan.

We help carry that clinical context across your care team, so you aren’t left taking a radiology report from one doctor’s office to another and explaining the findings yourself.

Radence stays involved, helping connect the right people, coordinate follow-up, and track what happens over time.

Seeing More Matters When You Know What to Do Next

If you are undergoing advanced imaging to look for disease before symptoms appear, the quality of the scan matters. So does everything surrounding it.

You want confidence that the protocol was designed to capture subtle findings and performed consistently. You want experienced radiologists interpreting the images. You want a clinical team considering those findings in the context of everything else known about your health.

And when something is found, you need answers to a different set of questions:

That is where Radence goes beyond testing.

When MRI raises a question it cannot fully answer, we help determine the right next test. When something deserves attention, we bring in your existing physicians or the appropriate specialists and help coordinate the next steps. When something needs to be followed, we continue looking for meaningful change over time.

Seeing more matters when you know what to do next. And when healthcare gets complicated, Radence stays with you.

See how BioAtlas fits into a more complete picture of your health.

BioAtlas gives us a detailed view of what is happening inside your body. Radence connects that information with the rest of your health to understand what matters, what deserves attention, and what should happen next.

Explore the Radence experience

Radence Standard of Care: Early Disease Detection Before Population Guidelines Catch Up

Most of modern medicine is designed to answer a population-level question: What is safe and effective for millions of people? Radence is different. We determine what is best for you, based on everything we know today.

By the time a clinical guideline is published and implemented, the underlying evidence may already be five to ten years old. Medical committees move slowly because they must balance safety, liability, cost, and applicability across broad populations.

We apply evidence to individuals before guidelines catch up.

Our members undergo comprehensive cardiovascular, metabolic, genomic, imaging, and cancer screening assessments that generate a far richer understanding of their individual risk than guideline committees typically consider. That additional information changes what we can act on.

The Radence Framework Behind Every Recommendation

Our recommendations are based on four inputs:

Evidence quality: what the clinical literature, trials, and real-world data show today. Risk-benefit profile: the magnitude of potential upside relative to the likelihood and severity of harm. Expert alignment: how leading physicians and specialists interpret the evidence and where consensus is emerging. Member applicability: how well an intervention fits your biology, risk factors, goals, and willingness to adopt.

TechAtlas, RA Capital’s research group of PhDs and MDs, continuously evaluates these four inputs to develop individualized recommendations.

How We Evaluate Emerging Evidence

When evaluating new therapies, diagnostics, and preventive interventions, we start with the strongest available clinical data: large randomized controlled trials designed to determine whether an intervention truly causes a meaningful outcome.

We also evaluate:

Analyses of group trials Prospective cohort studies that track defined groups over time Retrospective analyses of existing data Case series Mechanistic and preclinical research

Each type of evidence contributes differently to understanding benefit, risk, and biological plausibility. Most importantly, we do not review evidence on a fixed schedule.

New publications, conference presentations, and clinical trial results are continuously evaluated as they emerge. The objective is to understand what today’s evidence supports for a member with a specific risk profile.

We Use a Risk-Proportionate Threshold

The most important decision in any clinical framework is determining how much evidence is enough to act. Radence answers that question differently than guideline bodies do by applying a risk-proportionate threshold:

Lower-risk interventions with meaningful potential upside may justify action earlier. Higher-risk interventions require substantially stronger evidence before they are recommended.

Consider three examples:

A whole-body MRI carries no radiation exposure and relatively low risk, while potentially identifying disease before symptoms develop. Because the downside is relatively low, emerging evidence may be sufficient to support its use in appropriately selected individuals. While a DEXA scan has some low-level radiation exposure, it is not zero. The benefit in identifying bone density issues before a fracture occurs, however, could be clinically significant and worthwhile, particularly in individuals with risk factors for osteoporosis, such as sedentary lifestyles and nutritional deficiencies. Scans such as Coronary CT angiography (CCTA) carry additional considerations, including radiation exposure, intravenous contrast, and potentially medication to optimize physiological parameters for imaging quality requirements. It can, however, provide a detailed assessment of soft and calcified coronary plaque burden.

Applying the same evidentiary standard to all three scenarios would be a mistake. Precision medicine requires matching the strength of evidence to the risk of action.

Why Expert Judgment Matters

Published evidence is necessary but rarely sufficient on its own.

Leading physicians often identify meaningful shifts in a field before those shifts appear in formal guidelines. Their interpretation of emerging evidence, real-world experience, and understanding of downstream effects provide critical context.

This is where our research network becomes particularly valuable. We continuously evaluate emerging biomedical evidence and maintain relationships with leading experts across cardiology, neurology, oncology, endocrinology, and precision diagnostics.

When experts independently converge on the same interpretation of new evidence, confidence increases. When experts disagree, that disagreement itself becomes important information. Consensus among experts doesn’t replace evidence. It helps contextualize it.

Precision Medicine Requires a Different Standard

Traditional clinical guidelines are designed for populations. Radence is designed for individuals. When we have access to whole-genome sequencing, advanced imaging, metabolic and cardiovascular phenotyping, cancer screening, health data tracked over time, we can evaluate emerging therapies in the context of your unique biology rather than a population average.

This requires a more demanding standard of interpretation, not a lower one. The evidence must be strong enough to support an individualized decision, not just a population recommendation. The result is a standard of care that evolves at the pace of scientific discovery rather than waiting for consensus to catch up.